Purpura, Petechiae

and Vasculitis

UCSF Dermatology

Last updated 9.17.10

Module Instructions

The following module contains a number of

green, underlined terms which are

hyperlinked to the dermatology glossary, an

illustrated interactive guide to clinical

dermatology and dermatopathology.

We encourage the learner to read all the

hyperlinked information.

Goals and Objectives

The purpose of this module is to help medical students develop a clinical approach to the initial evaluation and treatment of patients with petechiae and purpura.

After completing this module, the medical student will be able to:• Identify and describe the morphology of petechiae and

purpura

• Outline an initial diagnostic approach to petechiae or purpura

• Recognize patterns of petechiae that are concerning for life-threatening conditions

• Recognize palpable purpura as the hallmark lesion of leukocytoclastic vasculitis

• Name the common etiologies of vasculitides according to size of vessel affected

Purpura: The Basics

The term Purpura is used to describe red-purple lesions that result from the extravasation of blood into the skin or mucous membranes

Purpura may be palpable or non-palpable (flat/macular)

Macular purpura is divided into two morphologies based on size:• Petechiae: small lesions (< 3 mm)

• Ecchymoses: larger lesions (>5mm)

The type of lesion present is usually indicative of the underlying pathogenesis:• Macular purpura is typically non-inflammatory

• Palpable purpura is a sign of vascular inflammation (vasculitis)

Purpura: The Basics

All forms do not blanch when pressed

• Diascopy refers to the use of a glass slide to apply

pressure to the lesion, which can be useful in

distinguishing erythema secondary to vasodilation

(blanchable with pressure), from erythrocyte

extravasation (retains its red color)

Purpura may result from hyper- and hypo-

coagulable states, vascular dysfunction and

extravascular causes

Examples of Purpura

Petechia

Ecchymosis

Examples of Purpura

Ecchymoses

Petechiae

Mr. Chad Fields

Case One

Case One: History

HPI: Mr. Fields is a 42 year-old gentleman who presents to the ER with a 2-week history of a rash on his abdomen and lower extremities.

PMH: hospitalization 1 year ago for community acquired pneumonia

Medications: none

Allergies: none

Family History: unknown

Social History: marginally housed, no recent travel or exposure to animals

Health Related Behaviors: smokes 10 cigarettes/day, drinks 3-10 beers/day, limited access to food

ROS: easy bruising, bleeding from gums, overall fatigue

Case One: Exam

Perifollicular petechiae

Keratotic plugging of hair follicles

Case One: Exam

Mr. Fields also has

hemorrhagic gingivitis

Case One, Question 1

Which of the following is the most likely

diagnosis?

a. drug hypersensitivity reaction

b. urticaria

c. vasculitis

d. rocky mountain spotted fever

e. nutritional deficiency

Case One, Question 1

Answer: e

Which of the following is the most likely diagnosis?

a. drug hypersensitivity reaction (typically without purpuric lesions)

b. urticaria (would expect raised edematous lesions, not purpura)

c. vasculitis (purpura would not be perifollicular and would be palpable)

d. rocky mountain spotted fever (no history of travel or tick bite)

e. nutritional deficiency

Vitamin C Deficiency - Scurvy

Scurvy results from insufficient vitamin C intake (i.e. fad diet, alcoholism), increased vitamin requirement (i.e. certain medications), and increased loss (i.e. dialysis)

Vitamin C is required for normal collagen structure and its absence leads to skin and vessel fragility

Characteristic exam findings include:• perifollicular purpura

• large ecchymoses on the lower legs

• intramuscular and periosteal hemorrhage

• keratotic plugging of hair follicles

• hemorrhagic gingivitis (when patient has poor oral hygeine)

Remember to take a dietary history in all patients with purpura

Case Two

Mr. Andrew Thompson

Case Two: History

HPI: Andrew is a 19 year-old gentleman who was admitted to the hospital with a headache, stiff neck, high fever, and a rash. His symptoms began 2-3 days prior to admission when he developed fevers with nausea and vomiting.

PMH: splenectomy 3 years ago after a snowboarding accident

Medications: none

Allergies: none

Vaccination hx: last vaccination as a child

Family history: not contributory

Social history: attends a near-by state college, lives in a dormitory

Health related behaviors: reports occasional alcohol use on the weekends with 2-3 drinks per night, plays basketball with friends for exercise.

ROS: as mentioned in HPI

Case Two: Exam

Vitals: T 102.4 ºF, HR 120, BP 86/40, RR 20, O2 sat 96% on room air

Gen: ill-appearing male lying on a gurney

HEENT: PERRL, EOMI, + nuchalrigidity

Skin: petechiae and large ecchymotic patches on upper (not shown) and lower extremities = Purpura fulminans

Case Two: Initial Labs

WBC count:14,000 cells/mcL

Platelets: 100,000/mL

Decreased fibrinogen

Increased PT, PTT

Blood Culture: gram negative diplococci

Lumbar puncture: pending

Case Two, Question 1

In addition to fluid resuscitation, what is the

most needed treatment at this time?

a. Plasmapheresis

b. IV antibiotics

c. Pain relief with oxycodone

d. IV corticosteroids

Case Two, Question 1

Answer: b

In addition to fluid resuscitation, what is the most needed treatment at this time?

a. Plasmaphoresis (not unless suspecting diagnosis of TTP)

b. IV antibiotics (may be started before lumbar puncture)

c. Pain relief with oxycodone (not the patient’s primary issue)

d. IV corticosteroids (not unless suspicion for pneumococcal meningitis is high)

Sepsis and DIC

Andrew’s clinical picture is concerning for meningococcemia with disseminated intravascular coagulation (DIC)

Presence of petechial or purpuric lesions in the patient with meningitis should raise concern for sepsis and DIC

Neisseria meningitis is a gram negative diplococcus that causes meningococcal disease • Most common presentations are meningitis and

meningococcemia

DIC results from unregulated intravascular clotting resulting in depletion of clotting factors and bleeding• The primary treatment is always to treat the underlying condition

Rocky Mountain Spotted Fever

Another life-threatening diagnosis to consider in a patient with a petechial rash is Rocky Mountain Spotted Fever (RMSF)

The most commonly fatal tickborne infection (caused by Rickettsia rickettsii) in the US

A petechial rash is a frequent finding that usually occurs several days after the onset of fever

Initial appearance of the rash is characterized by faint macules on the wrists or ankles. As the disease progresses, the rash may become petechial and involves the trunk, extremities, palms and soles

Majority of patients do not have the classic triad of fever, rash and history of tick bite

Clinical Evaluation of Purpura

A history and physical exam is often all that is necessary

Important history items include: • Family history of bleeding or thrombotic disorders (ie von

Willebrand disease)

• Use of drugs and medications (i.e. aspirin, warfarin) that may affect platelet function and coagulation

• Medical conditions (i.e. liver disease) that may result in altered coagulation

Complete blood count with differential and PT/PTT are used to help assess platelet function and evaluate coagulation states

Causes of Non-Palpable Purpura

Petechiae

• Thrombocytopenia

• Idiopathic

• Drug-induced

• Thrombotic

• DIC and infection

• Abnormal platelet function

• Increased intravascular

venous pressures

• Some inflammatory skin

diseases

Ecchymoses

• External trauma

• DIC and infection

• Coagulation defects

• Skin weakness/fragility

• Waldenstrom

hypergammaglobulinnemi

c purpura

Palpable Purpura

Palpable purpura results from inflammation of

small cutaneous vessels, ie vasculitis

Vessel inflammation results in vessel wall damage

and in extravasation of erythrocytes seen as

purpura on the skin

Vasculitis may occur as a primary process or may

be secondary to another underlying disease

Palpable purpura is the hallmark lesion of

leukocytoclastic vasculitis (small vessel vasculitis)

Vasculitis Morphology

Vasculitis is classified by the vessel size affected (small,

medium, mixed size or large)

Clinical morphology correlates with the size of the affected

blood vessels

• Small vessel: palpable purpura (urticarial lesions in rare cases, ie

urticarial vasculitis)

• Small-to medium-sized vessels: subcutaneous nodules, purpura and

FIXED livedo reticularis (also called livedo racemosa)

• Large-vessel disease: claudication, ulceration and necrosis

Diseases may involve more than one size of vessel

Systemic vasculitis may involve vessels in other organs

Vasculitides: Size of the Blood Vessel

Small vessel vasculitis (leukocytoclastic

vasculitis)

• Henoch-Schonlein purpura

• Urticarial vasculitis

• Other:

• Idiopathic

• Malignancy-related

• Rheumatologic

• Infection

• Medication

Vasculitides: Size of the Blood Vessel

Predominantly Mixed (Small + Medium)• ANCA associated vasculitides

• Churg-Strauss syndrome

• Wegener granulomatosis

• Microscopic polyarteritis

• Essential cryoglobulinemic vasculitis

Predominantly medium sized vessels• Polyarteritis nodosa

Predominantly large vessels• Takayasu arteritis

• Giant cell arteritis

Clinical Evaluation of Vasculitis

The following laboratory tests may be used to evaluate patient with suspected vasculitis:

• CBC with platelets

• ESR (systemic vasculitides tend to have sedimentation rates > 50)

• ANA (a positive antinuclear antibody test suggests the presence of an underlying connective tissue disorder)

• ANCA (help diagnose Wegener granulomatosis, microsopicpolyarteritis, drug-induced vasculitis, and Churg-Strauss)

• Complement (low serum complement levels may be present in mixed cryoglobulinemia, urticarial vasculitis and lupus)

• Urinalysis (helps detect renal involvement)

Also consider ordering cryoglobulins, an HIV test, HBV and HCV serology, occult stool samples, an ASO titer and streptococcal throat culture

Case Three

Jenny Miller

Case Three: History

HPI: Jenny is a 9 year-old girl with a 4-day history of abdominal pain and rash on the lower extremities who was brought to the ER by her mother. Her mother reported that the rash appeared suddenly and was accompanied by joint pain of the knees and ankles and aching abdominal pain. Over 3 days the rash changed from red patches to more diffuse purple bumps.

PMH: normal birth history, no major illnesses or hospitalizations

Medications: none, up to date on vaccines Allergies: none Family History: no history of clotting or bleeding disorders Social History: happy child when feeling well, attends

school, takes ballet ROS: cough and runny nose a few weeks ago

Case Three: Exam

Non-blanching erythematous

macules and papules on both

legs and feet sparing the

trunk, upper extremities and

face, diffuse petechiae

Case Three, Question 1

In this clinical context, what test will

establish the diagnosis?

a. HIV test

b. CBC

c. ESR

d. Urinalysis

e. Skin biopsy for routine microscopy and

direct immunofluorescence

Case Three, Question 1

Answer: e

In this clinical context, what test will establish

the diagnosis?

a. HIV test

b. CBC

c. ESR

d. Urinalysis

e. Skin biopsy for routine microscopy and direct

immunofluorescence

Skin Biopsy

A skin biopsy obtained from a new purpuric lesion

reveals a leukocytoclastic vasculitis of the small

dermal blood vessels

Direct immunofluorescence demonstrates

perivascular IgA, C3 and fibrin deposits

A skin biopsy is often necessary to establish the

diagnosis of vasculitis

Case Three, Question 2

What is the most likely diagnosis?

a. Urticaria

b. Disseminated intravascular coagulation

c. Henoch-Schonlein Purpura

d. Idiopathic thrombocytopenic purpura

e. Sepsis

Case Three, Question 2

Answer: c

What is the most likely diagnosis?

a. Urticaria

b. Disseminated intravascular coagulation

c. Henoch-Schonlein Purpura

d. Idiopathic thrombocytopenic purpura

e. Sepsis

Henoch Schonlein Purpura

Henoch Schonlein Purpura (HSP) is the most common form of systemic vasculitis in children

Primarily a childhood disease (between ages 3-15), but adults can also be affected

HSP follows a seasonal pattern with a peak in incidence during the winter presumably due to association with a preceding viral or bacterial infection

Characterized by palpable purpura (vasculitis), arthritis, abdominal pain and kidney disease

HSP: Diagnosis and Evaluation

Diagnosis often made on clinical presentation +/-

skin biopsy

Skin biopsy shows leukocytoclastic vasculitis in

postcapillary venules (small vessel disease)

• Immune complexes in vessel walls contain IgA deposition

(the diagnostic feature of HSP)

Rule out streptococcal infection with an ASO or

throat culture

HSP: Evaluation and Treatment

Also important to look for systemic disease:• Renal: Urinalysis, BUN/Cr

• Gastrointestinal: Stool guaiac

• HSP in adults may be a manifestation of underlying malignancy

Natural History: most children completely recover from HSP • Some develop progressive renal disease (more common

in adults)

Treatment is supportive +/- prednisone

Mr. Matthew Burton

Case Four

Case Four: History

Hospital Course: Mr. Burton is a 45 year-old

gentleman who was admitted to the hospital five

weeks ago with acute bacterial endocarditis. After

an appropriate antibiotic regimen was started and

Mr. Burton was stable, he was transferred to a

skilled nursing facility to finish a six-week course of

IV antibiotics. On week #5, the patient developed a

rash on his lower extremities. The dermatology

service was consulted to evaluate the rash.

Case Four: History Continued

PMH: history of community-acquired pneumonia 2

years ago, history of multiple skin abscesses

requiring incision and drainage (last abscess 2

months ago)

Medications: IV Vancomycin

Allergies: none

Social history: lives by himself in an apartment

Health-related behaviors: history of IV drug use

ROS: no current fevers, sweats or chills

Case Four: Skin Exam

Normal vital signs

General: appears well in NAD

Skin exam: palpable hemorrhagic papules coalescing into plaques, bilateral and symmetric on lower extremities

Also with bilateral and symmetric pedal edema

Labs: normal CBC, PT,PTT, INR

ANA < 1:40

Negative ANCA, cyroglobulins

HIV negative, Negative hep serologiesexcept for HBVsAb positive

Case Four, Question 1

Which of the following is the most likely cause of

Mr. Burton’s skin findings?

a. Leukocytoclastic vasculitis secondary to

antibiotics

b. Septic emboli with hemorrhage

c. Urticarial vasculitis

d. DIC secondary to sepsis

Case Four, Question 1

Answer: a

Which of the following is the most likely cause of

Mr. Burton’s skin findings?a. Leukocytoclastic vasculitis secondary to

antibiotics

b. Septic emboli with hemorrhage (these lesions tend to

occur on the distal extremities)

c. Urticarial vasculitis (presents with a different

morphology, which is more nodular and less diffuse)

d. DIC secondary to sepsis (in DIC, coagulation studies

are abnormal)

Case Four, Question 2

What is the most important next step?

a. Stop the IV antibiotics and replace with another

b. Obtain a urinalysis

c. Start systemic steroid

d. a & b

e. a & c

Case Four, Question 2

Answer: d

What is the most important next step?a. Stop the IV antibiotics and replace with another

(remove the offending agent)

b. Obtain a urinalysis (detection of renal involvement

will impact treatment)

c. Start systemic steroid (typically used when

vasculitis is systemic or severe)

d. a & b

e. a & c

Take Home Points: Petechiae & Purpura

The term purpura is used to describe purpuric lesions that result from extravasation of blood into the skin or mucous membranes

Purpura may be palpable and non-palpable

Purpura does not blanch with pressure

Various life-threatening conditions present with petechial rashes including meningococcemia and RMSF

The presence of petechial or purpuric lesions in a septic patient should raise concern for DIC

Purpura may result from hyper- and hypocoagulablestates, vascular dysfunction and exrtravascular causes

Take Home Points: Vasculitis

Palpable purpura results from underlying blood

vessel inflammation (vasculitis)

Palpable purpura is the hallmark lesion of

leukocytoclastic vasculitis

The various etiologies of vasculitis may be

categorized according to size of vessel affected

A skin biopsy is often necessary for the diagnosis

of vasculitis

End of Module

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Dedeoglu F, Kim S, Sundel R. Clinical manifestations and diagnosis of Henoch-Schönleinpurpura. Uptodate.com. June 2010.

Fatal Cases of Rocky Mountain Spotted Fever in Family Clusters --- Three States, 2003. MMWR Weekly May 21, 2004/53(19);407-410.

Gota Carmen E, Mandell Brian F, "Chapter 165. Systemic Necrotizing Vasculitis" (Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e: http://www.accessmedicine.com/content.aspx?aID=2993241.

Hunder GG. Treatment of giant cell (temporal) arteritis. Uptodate.com. June 2008.

Hunder GG. Classification of and approach to the vasculitides in adults. Uptodate.com. May 2008.

James WD, Berger TG, Elston DM, “Chapter 35. Cutaneous Vascular Diseases” (chapter). Andrews’ Diseases of the Skin Clinical Dermatology. 10th ed. Philadelphia, Pa: Saunders Elsevier; 2006: 820-845.

Rashid Bina A, Houshmand Elizabeth B, Heffernan Michael P, "Chapter 145. Hematologic Diseases" (Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e: http://www.accessmedicine.com/content.aspx?aID=2989841.

Rosenstein NE, Perkins BA, Stephens DS, Popovic T, Hughes JM. Meningococcal Disease. Review Article. N Endl J Med. 2001;344:1378-1388.

The Dermatology Glossary, http://missinglink.ucsf.edu/lm/DermatologyGlossary/index.html